Patient-reported outcomes serve as an essential and perhaps more relevant means for assessing patients’ response to treatment than clinical measures alone. Many of the procedures performed in plastic surgery are associated with aesthetic outcomes. Therefore, it is pertinent to thoroughly understand the patient’s perspective of achieved results. Surgeons need to possess knowledge and skills about outcomes assessments and understand how to apply them to improve quality of care delivered based on evidence. This article discusses the appropriate use of outcome questionnaires to rigorously evaluate treatment methods based on patient satisfaction and the outcome measurement instruments frequently used in plastic surgery.
Key points
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If well-developed and validated tools are available for a condition, there is little need to develop new questionnaires except when they are simpler or provide enhanced information.
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Future efforts should focus on enabling the process of data collection and analysis through questionnaires simple enough to facilitate the regular use of these tools in clinical practice.
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In the current era of outcomes assessment and evidence-based medicine, it is essential for plastic surgeons to keep well-informed about the latest developments in understanding the assessment tools available to achieve enhanced patient satisfaction and quality of care.
Overview
Outcomes assessment is an integral component of evaluating the success of various medical and surgical procedures in the evidence-based era. Rather than relying on traditional “hard” outcomes data, such as how far one can walk after lower leg reconstruction or how much breast tissue is resected in breast reduction surgery, physicians and patients are much more interested in patients’ perception of their functional improvement, quality of life, and satisfaction with treatment. Such appraisal is vital not only for clinicians but also to patients. Patients are constantly trying to derive maximum information from their surgeon with regard to the outcomes of the procedures they undergo. These inquiries extend farbeyond recovery and functional restoration. In plastic surgery, patients want to be reassured of other critical aspects of care, such as satisfaction, physical and social well-being, and aesthetic appearances as a result of an intervention.
Traditionally, outcomes are measured in the form of assessments made by the treating plastic surgeon through photographs, anatomic measurements, and complications. However, the perception of results by a surgeon and patient differ. A plastic surgeon may be content with the results obtained from his or her treatment, but the patient may not be similarly pleased with the outcomes achieved. Therefore, outcomes measured from the patient’s viewpoint are highly relevant because most of the procedures performed in plastic surgery aim at improving physical appearance, body image, psychosocial function, and quality of life. Acceptance by friends and family, emotional and mental satisfaction, confidence, and happiness with appearance after an intervention influence quality-of-life outcomes. The volume of plastic surgery procedures is huge, and ever increasing. Procedural statistics from the American Society of Plastic Surgeons showed that 5.5 million reconstruction procedures and 1.6 million cosmetic surgical procedures were performed in the year 2011 with an increase of 5% and 2%, respectively, over the year 2010. Therefore, subsequent assessment of outcomes from the patient’s perspective is relevant in plastic surgery.
Measures to quantify the results in plastic surgery are a recent trend and in the last two decades several outcomes questionnaires or surveys in the form of patient-reported outcomes (PRO) were developed and used. However, all of these outcomes tools are not validated. Encouragingly, the last decade has seen much progress in this area and attempts to develop more robust measurement tools continue. Plastic surgery is a unique field in which outcomes are not assessed alone by mortality and morbidity. Therefore, patient satisfaction and quality-of-life components take prime importance. The future and success of this specialty depends heavily on the patients’ perception of their outcomes. The ultimate goal is to have outcomes measures that incorporate patient satisfaction and all of the quality-of-life measures that can potentially reflect the real effect of a surgical intervention. This article educates readers about how to use these tools to measure patient satisfaction and outcomes achieved in a more meaningful and coherent manner. It also informs readers about the common pearls and pitfalls encountered during use of these questionnaires.
Overview
Outcomes assessment is an integral component of evaluating the success of various medical and surgical procedures in the evidence-based era. Rather than relying on traditional “hard” outcomes data, such as how far one can walk after lower leg reconstruction or how much breast tissue is resected in breast reduction surgery, physicians and patients are much more interested in patients’ perception of their functional improvement, quality of life, and satisfaction with treatment. Such appraisal is vital not only for clinicians but also to patients. Patients are constantly trying to derive maximum information from their surgeon with regard to the outcomes of the procedures they undergo. These inquiries extend farbeyond recovery and functional restoration. In plastic surgery, patients want to be reassured of other critical aspects of care, such as satisfaction, physical and social well-being, and aesthetic appearances as a result of an intervention.
Traditionally, outcomes are measured in the form of assessments made by the treating plastic surgeon through photographs, anatomic measurements, and complications. However, the perception of results by a surgeon and patient differ. A plastic surgeon may be content with the results obtained from his or her treatment, but the patient may not be similarly pleased with the outcomes achieved. Therefore, outcomes measured from the patient’s viewpoint are highly relevant because most of the procedures performed in plastic surgery aim at improving physical appearance, body image, psychosocial function, and quality of life. Acceptance by friends and family, emotional and mental satisfaction, confidence, and happiness with appearance after an intervention influence quality-of-life outcomes. The volume of plastic surgery procedures is huge, and ever increasing. Procedural statistics from the American Society of Plastic Surgeons showed that 5.5 million reconstruction procedures and 1.6 million cosmetic surgical procedures were performed in the year 2011 with an increase of 5% and 2%, respectively, over the year 2010. Therefore, subsequent assessment of outcomes from the patient’s perspective is relevant in plastic surgery.
Measures to quantify the results in plastic surgery are a recent trend and in the last two decades several outcomes questionnaires or surveys in the form of patient-reported outcomes (PRO) were developed and used. However, all of these outcomes tools are not validated. Encouragingly, the last decade has seen much progress in this area and attempts to develop more robust measurement tools continue. Plastic surgery is a unique field in which outcomes are not assessed alone by mortality and morbidity. Therefore, patient satisfaction and quality-of-life components take prime importance. The future and success of this specialty depends heavily on the patients’ perception of their outcomes. The ultimate goal is to have outcomes measures that incorporate patient satisfaction and all of the quality-of-life measures that can potentially reflect the real effect of a surgical intervention. This article educates readers about how to use these tools to measure patient satisfaction and outcomes achieved in a more meaningful and coherent manner. It also informs readers about the common pearls and pitfalls encountered during use of these questionnaires.
Patient Reported Outcomes Measurement Information System and its development
PRO helps to associate the outcomes achieved with the care provided from the patient’s perspective. Rising costs of health care and restricted funding environments have led surgeons to find cost-effective measures to sustain health care delivery for the present and future. Outcomes assessments with the aid of patient questionnaires can partially achieve this task. The federal government has devoted substantial funding for the Patient Reported Outcomes Measurement Information System (PROMIS) initiative under National Institutes of Health guidance in 1994. The primary goal of this multicenter (12 sites) research project is to develop valid, reliable, and standardized tools to assess PRO. PROMIS uses item banks to generate instruments that can be used as primary or secondary end points in clinical studies that evaluate treatment effectiveness. These outcomes measures help assess various chronic conditions so outcomes can be comparable across studies.
Types of available outcomes questionnaires
PRO are obtained from patient interviews or questionnaires completed by patients during several follow-ups in the treatment process. Two types of questionnaires are available for use: generic questionnaires and disease-specific questionnaires. Each questionnaire has certain advantages and disadvantages associated with them because they were originally designed for different purposes. As a result, it is important to differentiate between them before proceeding with their use.
Generic questionnaires are designed to assess the disease effect on the whole person irrespective of the medical condition. They are broad and can be used for an overall health assessment after an intervention, as an accompaniment to disease-specific questionnaires, and when disease-specific questionnaires are not yet designed and available. For instance, Short Form 36 (SF-36) and Sickness Impact Profile can be used in a variety of conditions. SF-36 is a widely used generic measure along with specific measures to assess eight health domains. Generic measures incorporate various qualitative and quantitative aspects of human life. Each questionnaire is unique, so they provide researchers an opportunity to work with one or few questionnaires simultaneously and an ability to compare outcome results across different conditions. However, they lack the precision and sensitivity to detect specific changes after an intervention.
Disease-specific questionnaires are designed to assess interventions in patient populations identified by a particular disease. They are more responsive than general questionnaires because they are sensitive to detect changes due to focused questions. They are useful to evaluate specific interventions and differences between two similar treatments. For example, the Nasal Appearance and Function Evaluation Questionnaire can be used to assess functional and aesthetic outcomes after nasal reconstruction. Similarly, the Carpal Tunnel Questionnaire is a valid and reliable tool to assess symptom and functional changes after carpal tunnel surgery. The Michigan Hand Outcomes Questionnaire (MHQ) is another valid questionnaire with six health domains that is used all over the world to evaluate outcomes in patients with hand conditions. It also collects the data on the unaffected hand to be used as a control for the comparison of outcomes.
A disease-specific instrument is designed to assess specific interventions. However, when a specific instrument addresses all aspects of intervention but fails to consider quality-of-life domains, such as psychosocial and sexual functioning, a generic instrument should be used as an accompaniment. For example, the Breast-related Symptoms Questionnaire used to evaluate outcomes after breast reduction assesses only breast symptoms. A generic questionnaire can be used to evaluate a specific treatment when a disease-specific instrument is not available. For instance, Dolan and colleagues used SF-36 to assess health-related quality-of-life outcomes after microvascular free flap reconstruction. However, the use of a specific questionnaire to assess general health cannot accomplish the expected purpose because it fails to incorporate the items beyond the specific condition. A list of available outcomes questionnaires in plastic surgery with their component scales and specific use is outlined in Table 1 .
| Name | Purpose | Component Scales/Items | Developed by |
|---|---|---|---|
| Breast | |||
| BREAST-Q | To assess impact and effectiveness of breast surgery | Three modules: augmentation, reduction, and reconstruction Six scales: psychosocial well-being, physical, and sexual well-being, satisfaction with breasts, satisfaction with outcome, and satisfaction with care | Pusic et al. |
| Breast Evaluation Questionnaire | To assess patient satisfaction with breast attributes and quality of life outcome after breast surgery | 55 items: degree of comfort with size, appearance of the breasts, and satisfaction level achieved | Anderson et al. |
| Outcomes of Plastic Surgery, hand/arm questionnaire | To assess outcomes of plastic surgery of hand and arm | Symptoms, limitation of daily activities, psychological functioning/cosmetic appearance, and patient satisfaction | |
| European Organization for Research and Treatment of Cancer Quality of Life questionnaire C30 1 | Breast module (Br 23) items assess disease symptoms, side effects of treatment, body image, sexual functioning, and future perspectives | Nine scales: five functional, three symptom, and one global health-related quality-of-life scale Used to assess patients with cancer | |
| Face | |||
| FACE-Q | To assess impact and effectiveness of facial aesthetic procedures | Four scales: satisfaction with facial appearance, health-related quality of life, negative sequelae, and satisfaction with process of care | Klassan et al. |
| Facial Injectables, Longevity, Late and Early Reactions and Satisfaction Questionnaire | Physical and social experiences after treatment with injectable facial soft tissue fillers | 43 items: patient demographics (4); patient satisfaction with treatment (10); procedure-related events (3–7); impact on relationships (9–15); and economic considerations (3–7) | Sclafani et al. |
| Facial Clinimetric Evaluation Scale | Measures facial impairment and disability | 15 items, six domains: facial movement, facial comfort, oral function, eye comfort, lacrimal control, and social function Used to assess patients with facial paralysis | Baylor College of Medicine, Houston, Texas |
| Facial Disability Index | Measures disability and social and emotional well-being of facial paralysis patients | 10 items, two domains- social/wellbeing function and physical function | |
| Facial Lines Treatment Satisfaction | To assess patient satisfaction with facial line treatment | 14 items measuring facial line appearance, procedure satisfaction, and patient confidence | Allergan |
| Facial Lines Outcome Questionnaire | To measure hyperfunctional facial lines of the upper face | Seven items | Allergan |
| Derriford Appearance Scale | Physical and psychosocial aspects of facial and bodily appearance | Six measures of psychological distress and dysfunction and one measure of physical distress and dysfunction | |
| Rhinoplasty Outcomes Evaluation | Used to assess patients after rhinoplasty surgery | Six items, three domains: appearance, functional outcome, and social acceptance | Alsaraff |
| Blepharoplasty Outcomes Evaluation | Used to assess patients after blepharoplasty surgery | Three domains: appearance, functional outcome, and social acceptance | Alsaraff |
| Facelift Outcomes Evaluation | Used to assess patients after facelift surgery | Three domains: appearance, functional outcome, and social acceptance | Alsaraff |
| Skin Rejuvenation Outcomes Evaluation | Used to assess patients after skin resurfacing surgery | Three domains: appearance, functional outcome, and social acceptance | Alsaraff |
| Louisville Instrument For Transplantation | Used to assess patients after composite tissue allotransplantation surgery | Quality of life improvement, aesthetic and functional outcomes | Cunningham et al. |
| Glassgow Benefit Inventory | Measures general perception of well-being, social and physical well-being | 18 items, general benefit scale, social support scale, and physical health status scale Used to assess patients after head and neck surgery, especially functional and cosmetic rhinoplasty | |
| Aesthetic Surgery | |||
| Multidimensional Body-States Relations Questionnaire | To assess body image | Has psychological, body image, and general questions 10 subscales to assess individual’s satisfaction with five dimensions of body image | |
| Body Dysmorphic Disorder Questionnaire | To assess body dysmorphic disorder | Four sets of questions | Phillips et al. |
| Dysmorphic Concern Questionnaire | Used to assess patients with concern on physical appearance | Seven questions | Oosthuizen et al. |
Related posts:
Patient-Reported Outcomes Instruments
The Outcomes Movement and Evidence-Based Medicine in Plastic Surgery
Development and Psychometric Evaluation of the FACE-Q Satisfaction with Appearance Scale
Measuring Outcomes in Craniofacial and Pediatric Plastic Surgery
Measuring Outcomes in Hand Surgery
Measuring Outcomes in Lower Limb Surgery
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